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The managed care organization (MCO) must require all providers rendering Long-Term Services and Support (LTSS), with the exception of atypical providers, to use the CMS 1500 Claim Form or the HIPAA 837 Professional Transaction when billing. Atypical providers are LTSS providers that render non-health or non-medical services to STAR+PLUS members. Examples include pest control services and building and supply services.
Providers using the Paper CMS 1500
Providers billing on paper will provide complete information about the service event and will use the state assigned provider identification (ID) to represent the provider(s) involved in the service event. The provider ID (billing and/or rendering) will be located in Block 33 on the paper form.
- If the billing provider and the rendering provider are the same, then the state assigned provider ID will be populated in Block 33.
- If the rendering provider is different than the billing provider, then the billing provider state assigned provider ID will be populated in Block 33, and the rendering provider state assigned provider ID will be populated in Block 24K.
- Under specific scenarios, the additional usage of Block 17a (Referring Provider (Optional)) and Block 24k can be used to report additional information on providers that are involved in the service event.
Providers using the Electronic HIPAA 837
Providers billing electronically will comply with HIPAA 837 guidelines, including the accurate and complete conveyance of information pertaining to the provider(s) involved in the service event.
Atypical providers will submit appropriate documentation to the MCO. The MCO must obtain sufficient documentation from the atypical provider to accurately populate an 837 professional encounter. Refer to the HIPAA-compliant 837 Professional Combined Implementation Guide and the 837 Professional Companion Guide for further information. (See “Claims Processing Requirements” in §2, Claims, in the UMCM.)
Providers and MCOs will bill and report LTSS in compliance with the STAR Kids Billing Matrix (Matrix).
Providers – LTSS providers must use the “designated position” of the modifiers, as indicated on the Matrix, when filing claims.
MCOs – MCOs must use the “designated position” of the modifiers, as indicated on the Matrix, when reporting encounters.
Nursing Facilities (NFs) – Services pertaining to a member entering a nursing facility will be filed (paper or electronic) through the state’s claims administrator under traditional Medicaid (fee for service) following the claims submission guidelines applicable to traditional Medicaid billing. Services that do not involve a member entering a nursing facility (i.e., respite care) will conform to normal LTSS billing procedures.
The LTSS Bulletin posted on the Texas Medicaid Health Partnership website (www.tmhp.com) provides additional information and updates.